Inside Health

With Toughness and Caring, a Novel Therapy Helps Tortured Souls

By BENEDICT CAREY

Published: July 13, 2004

SEATTLE—
''I've been going through this since I was 11 years old,'' the young woman said, ''I'm backed up against the wall. Either I need to do this therapy or I need to die.''

''Well, why not die?'' the therapist asked.

''Well, if it comes down to it, I will.''

''Uh-huh, but why not now?''

This aggressive cross-examination is a signature technique of what has become one of the most popular new psychotherapies in a generation.

For years, psychotherapists have had a wide array of techniques to draw from in helping troubled patients. The most commonly discussed recent therapies teach interpersonal skills for improving relationships or cognitive skills for defusing upsetting thoughts. But even the best therapies are worth little if patients are too defiant, too desperate or too upset to accept help.

That is why clinicians and health officials around the world are trying out a provocative approach called dialectical behavior therapy. Developed at the University of Washington by Dr. Marsha Linehan, a researcher and clinician who was the therapist in the above exchange, dialectical techniques have proved effective in the most difficult-to-reach cases, sometimes saving the lives of intensely suicidal people.

Other therapies, Dr. Linehan said, implied that the patients were the problem, and that they could change if they wanted to.

''But these are people who have been told all their lives that they are the problem,'' she said, adding, ''We needed a new approach.''

Already, more than a dozen states have incorporated the therapy in their mental health systems, as have scores of forensic hospitals, drug treatment centers and prisons in the United States, Australia, Britain and Germany. Word is moving fast, experts say, because any well-defined approach that gets through to suicidal patients holds promise for other hard cases: drug addicts, people with bulimia, severely depressed adolescents, the defiant and the antisocial.

In a health field starved for innovation, in which treatments are notoriously difficult to define, study and standardize, Dr. Linehan's manuals and underlying philosophy represent the most significant new effort in decades, some experts believe.

''It's an extremely hot therapy now because it deserves to be,'' said Dr. Steve Hollon, a professor of psychology at Vanderbilt University.

Other experts caution that the excitement over the therapy has outpaced the science.

''It concerns me that so many states are mandating this treatment when we only have yearlong studies, and we don't know if it really eliminates the problem long term,'' said Dr. Drew Westen, a professor of psychiatry, psychology and behavioral sciences at Emory University.

Still, he said, ''the therapy seems to help patients regulate their emotions when they're spiraling out of control, and that, to me, would be a real, enduring contribution to the field.''

Dr. Linehan first developed the therapy as a way to help people with borderline personality disorder, an enigmatic and notoriously difficult condition to treat.

Borderline patients are often severely self-destructive, cutting or burning themselves and attempting suicide. In therapy, they are often manipulative, mercurial, at times chillingly mute. They wear out therapists and try the patience of friends and family members. (The needy, compulsive, violent character played by Glenn Close in the 1987 movie ''Fatal Attraction,'' who seduces a married man and then stalks him when he rejects her, exhibits borderline behavior, some say.)

Some researchers believe that the disorder develops as a result of uncertain attachments to parents early in life. Others are searching for biological roots. One study, for example, found that borderline patients exhibited hyperactivity in the amygdala, a part of the brain involved in emotion regulation. Some patients, experts say, are helped by mood-stabilizing drugs.

Yet dialectical therapy neither involves drugs nor concerns itself much with biology. It begins with an idea called radical acceptance, the insistence that people in therapy accept who they are and that they are not who they want to be. They cannot go back and repair their childhood, as awful as it might have been. They have blown precious relationships for good. Most of all, they experience waves of rage, emptiness and despair far more intensely than other people do.

The therapist, in turn, acknowledges that self-harming behaviors and suicide attempts actually make some sense. They are expected responses to profound distress; though dysfunctional, they provide relief.

''You're meeting them right where they are if you say, 'I realize this behavior has been a good coping skill for you,''' said Marjorie Burns, a therapist in Fort Wayne, Ind., who has used dialectic techniques to help troubled adolescents, as well as people with bipolar and eating disorders. ''It normalizes the behavior in a way, and shows some compassion.''

But the patients also come to realize they have only two choices: change or stay miserable. The woman who Dr. Linehan treated, for example, said she saw the treatment as her only hope.

''So, in other words, all things being equal, you'd rather live than die, if you can pull this off?'' Dr. Linehan asked the woman.